ID
A 25-year-old female who recently moved to the area comes in for a well woman visit. She reports that she has had yearly Papanicolaou (Pap) tests and sexually transmitted infection (STI) screening since age 21 with no abnormal results. She has had a total of six sexual partners. She is asymptomatic and does not have any history of STIs or new partners in the past year. Your nurse informs her that STI screening can be done, but a Pap test is not necessary at this time. The patient is concerned about not having a Pap test this year and asks you why it is not recommended. You explain that the most important reason is that
A) she has no history of STIs
B) she has had several normal Pap tests in a row
C) she is in a low-risk group for HPV infection
D) Pap test abnormalities would require no further evaluation in a patient her age
E) the risk of harm from unnecessary procedures and treatment exceeds the potential benefit at her age
(E) Annual HPV screening in patients age 21–29 years has very little effect on cancer prevention and leads to an increase in procedures and treatments without significant benefit. In this age group there is a high prevalence of high-risk HPV infections but a low incidence of cervical cancer. If this patient were due for a Papanicolaou (Pap) test and results were ASC-US with a positive high-risk HPV or a higher grade abnormality, colposcopy would be recommended. Current recommendations are for a Pap test with cytology every 3 years for women age 21–29 years with normal results, and the frequency does not change with an increased number of normal screens. HPV is the most common sexually transmitted infection (STI) and up to 79% of sexually active women contract HPV infection in their lifetime, so the lack of other STIs does not preclude the possibility of an HPV infection.
A 32-year-old male presents with a 4-week history of persistent low back pain. He started feeling tightness in his low back after helping a friend move into a new apartment. The pain does not radiate, there is no associated paresthesia or numbness, and he has not had any bowel or bladder incontinence. The pain is constant and worsens with prolonged sitting. He rates the pain as 6 on a scale of 10. Ibuprofen has provided minimal relief. Examination of the lumbar area over the paraspinous muscles reveals minimal tenderness. A neurovascular examination and a straight leg raise are normal in both lower extremities. Which one of the following would be most appropriate at this point?
A) Imaging studies of the lumbar spine
B) A short course of an oral corticosteroid
C) Gabapentin (Neurontin) started at a low dose and titrated to effect
D) A skeletal muscle relaxant and an NSAID
E) A short-acting opioid and an NSAID
ANSWER: (D) This patient has acute to subacute nonspecific low back pain. Combination treatment with an NSAID and a skeletal muscle relaxant is recommended as second-line therapy when an NSAID is ineffective as monotherapy. Opioids have not been shown to have significant benefit when added to an NSAID and would not be recommended as a second-line treatment. Systemic corticosteroids do not have evidence to support their use in the treatment of acute nonspecific back pain. Gabapentin does not have evidence to support its use in treating acute back pain and has been shown to produce only minimal improvement in chronic back pain. This patient has no red-flag symptoms so imaging studies are not recommended at this time.
A 25-year-old female sees you because of irregular menses, hirsutism, and moderate acne. She is sexually active in a monogamous relationship with a male, has never been pregnant, and prefers not to become pregnant at this time. Which one of the following is considered first-line therapy?
A) Clomiphene (Clomid)
B) Letrozole (Femara)
C) Levonorgestrel/ethinyl estradiol
D) Metformin (Glucophage)
E) Spironolactone (Aldactone)
ANSWER: (C) The Endocrine Society recommends hormonal contraception as the first-line medication for women diagnosed with polycystic ovary syndrome (PCOS) who are experiencing irregular menses, acne, and hirsutism and do not desire pregnancy (SOR A). Metformin may help regulate menses but has not been shown to be as effective as oral hormone therapy. In a 2015 Cochrane review, oral contraceptives were recommended as the most effective treatment for hirsutism. Either letrozole or clomiphene is appropriate for women diagnosed with PCOS who want to become pregnant.
Which one of the following is the leading cause of cancer death in men in the United States?
A) Colorectal cancer
B) Liver cancer
C) Lung cancer
D) Non-melanoma skin cancer
E) Prostate cancer
ANSWER: C According to the CDC, the leading causes of cancer death in men from 2011–2015 were lung cancer (53.8 deaths per 100,000 per year), prostate cancer (19.5 deaths per 100,000 per year), colorectal cancer (17.3 deaths per 100,000 per year), and pancreatic cancer (12.6 deaths per 100,000 per year).
A 45-year-old African-American male returns to your clinic to evaluate his progress after 6 months of dedicated adherence to a diet and exercise plan you prescribed to manage his blood pressure. His blood pressure today is 148/96 mm Hg. He is not overweight and he does not have other known medical conditions or drug allergies. Which one of the following would be the most appropriate initial antihypertensive treatment option for this patient?
A) Chlorthalidone
B) Hydralazine
C) Lisinopril (Prinivil, Zestril)
D) Losartan (Cozaar)
E) Metoprolol
ANSWER: (A) Lifestyle modifications addressing diet, physical activity, and weight are important in the treatment of hypertension, particularly for African-American and Hispanic patients. When antihypertensive drugs are also required, the best options may vary according to the racial and ethnic background of the patient. The presence or absence of comorbid conditions is also important to consider. For African-Americans, thiazide diuretics and calcium channel blockers, both as monotherapy and as a component in multidrug regimens, have been shown to be more effective in lowering blood pressure than ACE inhibitors, angiotensin II receptor blockers, or B-blockers, and should be considered as first-line options over the other classes of antihypertensive drugs unless a comorbid condition is present that would be better addressed with a different class of drugs. Racial or ethnic background should not be the basis for the exclusion of any drug class when multidrug regimens are required to reach treatment goals.
A 68-year-old male presents to your office with a 2-day history of headache, muscle aches, and chills. His wife adds that his temperature has been up to 104.1°F and he seems confused sometimes. His symptoms have not improved with usual care, including ibuprofen and increased fluid intake. He and his wife returned from a cruise 10 days ago but don’t recall anyone having a similar illness on the ship. This morning he started to cough and his wife was concerned because she saw some blood in his sputum. He also states that he experiences intermittent shortness of breath and feels nauseated. His blood pressure is 100/70 mm Hg, heart rate 98/min, temperature 39.4°C (102.9°F), and oxygen saturation 95% on room air. Which one of the following would be the preferred method to confirm your suspected diagnosis of Legionnaires’ disease?
A) Initiating azithromycin (Zithromax) to see if symptoms improve
B) A chest radiograph
C) Legionella polymerase chain reaction (PCR) testing
D) A sputum culture for Legionella
E) Urine testing for Legionella pneumophila antigen
ANSWER:
(E) A urine test for Legionella pneumophila antigen is the preferred method to confirm Legionnaires’ disease. This test is rapid and will only detect Legionella pneumophila antigen. A sputum culture is the gold standard for the diagnosis of Legionnaires’ disease but it requires 48–72 hours. A chest radiograph does not confirm the diagnosis but may show the extent of disease. Responding to antibiotic treatment does not confirm a specific diagnosis
A 45-year-old female who works as a house cleaner presents with left shoulder pain. On examination she has pain and relative weakness when pushing toward the midline against resistance while the shoulder is adducted and the elbow is bent to 90°. With the elbow still at 90° she is unable to keep her left hand away from her body when you position her hand behind her back. This presentation is most consistent with an injury of which one of the following tendons?
A) Deltoid
B) Infraspinatus
C) Subscapularis
D) Supraspinatus
E) Teres minor
ANSWER: (C) This patient’s pain and weakness while pushing against resistance reveals weakness on internal rotation of the shoulder, which suggests a possible tear of the subscapularis tendon. The inability to keep her hand away from her body when it is placed behind her back describes a positive internal lag test, also suggesting involvement of the subscapularis tendon. The infraspinatus and teres minor are involved in external rotation rather than internal rotation. The supraspinatus and deltoid are involved in abduction of the shoulder.
A 69-year-old male with type 2 diabetes mellitus, obesity, and a history of coronary artery disease sees you for follow-up of his diabetes. His hemoglobin A1c has increased to 8.7% despite therapy with metformin (Glucophage), 1000 mg twice daily, and insulin glargine (Lantus). Which one of the following additional medications would be most effective for reducing his blood glucose level and lowering his risk of cardiovascular events?
A) Exenatide (Byetta)
B) Glipizide (Glucotrol)
C) Liraglutide (Victoza)
D) Rosiglitazone (Avandia)
E) Sitagliptin (Januvia)
ANSWER: (C) Liraglutide, exenatide, and dulaglutide are all GLP-1 receptor agonists. Of these, only liraglutide has been shown to lower the risk of recurrent cardiovascular events and has received FDA approval for this indication. Glipizide (a sulfonylurea), rosiglitazone, and sitagliptin have not been associated with improved cardiovascular outcomes. Empagliflozin, an SGLT2 inhibitor, has also been associated with secondary prevention of cardiovascular disease.
At what age should screening for cervical cancer be discontinued in patients with no history of abnormal Pap smears?
A. 55 years
B. 60 years
C. 65 years
D. 70 years
E. 75 years
ANSWER: (C) The correct answer is 65 years. The U.S. Preventive Services Task Force (USPSTF) recommends against screening for cervical cancer in women older than 65 years of age who have had adequate prior screening and are not otherwise at high risk for cervical cancer. In patients who have a history of cervical cancer that is treated, continued screening is recommended for 20 years post-resolution regardless of age.
A 65-year-old male with type 2 diabetes mellitus, hypertension, and obstructive sleep apnea sees you for follow-up. He does not use tobacco or other drugs, and his alcohol consumption consists of two drinks per day. His BMI is 31.0 kg/m2 , and he just started a fitness program. The patient tells you that his brother was recently diagnosed with atrial fibrillation and he asks you if this increases his own risk. Which one of the following factors would increase the risk of atrial fibrillation in this patient?
A) Alcohol use
B) Treatment with lisinopril (Prinivil, Zestril)
C) Treatment with pioglitazone (Actos)
D) Use of a continuous positive airway pressure (CPAP) device
E) Physical stress
ANSWER:
(A) Alcohol consumption greater than one drink/day has been associated with atrial fibrillation. While not recommended to prevent atrial fibrillation, pioglitazone and lisinopril have both been associated with lower rates of atrial fibrillation compared to alternative therapies. Treatment of obstructive sleep apnea, along with a regular fitness regimen, has been associated with a decrease in the recurrence of atrial fibrillation.
A young mother, who is currently breastfeeding her 13-month-old infant, presents to the office with signs and symptoms of acute sinusitis. You decide to treat her with antibiotic therapy. She reports that she has not taken antibiotics recently and has no known medication allergies. The most appropriate course of action is to prescribe
A. amoxicillin (Amoxil®) and tell her that it is safe to continue breastfeeding
B. amoxicillin (Amoxil®) and tell her to pump and discard her breast milk while she is on the antibiotic, then resume breastfeeding
C. any antibiotic and advise her that infants should not be breastfed past 12 months of age
D. doxycycline (Doryx®) and tell her that it is safe to continue breastfeeding
E. levofloxacin (Levaquin®) and tell her to pump and discard her breast milk while she is on the antibiotic, then resume breastfeeding
ANSWER: (A) The correct answer is amoxicillin (Amoxil® ) and tell her that it is safe to continue breastfeeding. Amoxicillin (Amoxil® ) is acceptable to use during breastfeeding. Limited information indicates that single maternal doses of amoxicillin (Amoxil® ) 1 g produce low levels in milk that are not expected to cause adverse effects in breastfed infants. Occasionally, rash and disruption of the infant’s gastrointestinal flora, resulting in diarrhea or thrush, have been reported, but these effects have not been adequately evaluated. Discarding breast milk while the mother is on amoxicillin (Amoxil® ), therefore, is not necessary. Amoxicillin (Amoxil® ) is a drug of choice for the treatment of uncomplicated sinusitis, and is the most appropriate first-line option among the antibiotic choices. Tetracyclines are contraindicated during breastfeeding because of possible staining of infants’ dental enamel or bone deposition of tetracyclines. Sinusitis should be treated with an appropriate antibiotic; therefore, treatment with “any antibiotic” would be incorrect. In addition, it is incorrect to state that infants should not be breastfed past 12 months. Twelve months is a common goal for breastfeeding mothers, but it is safe and appropriate to continue breastfeeding beyond 12 months if the mother-baby pair is still thriving. Fluoroquinolones such as levofloxacin (Levaquin® ) have traditionally not been used in infants because of concern about adverse effects on the infants’ developing joints. Fluoroquinolones should be reserved for complicated sinusitis and if used, the breast milk should be discarded.
You are the team physician for the local high school track team. During a meet one of the athletes inadvertently steps off the edge of the track and inverts her right foot forcefully. She is able to bear weight but with significant pain. She reports pain across her right midfoot. An examination reveals edema over the lateral malleolus and diffuse tenderness, but she does not have any pain with palpation of the navicular, the base of the fifth metatarsal, or the posterior distal lateral and medial malleoli. Which one of the following would be most appropriate at this time?
A) Radiographs of the right ankle only
B) Radiographs of the right foot only
C) Radiographs of the right foot and ankle
D) Lace-up ankle support, ice, compression, and clinical follow-up
E) Crutches and no weight bearing for 2 weeks, followed by a slow return to weight bearing
ANSWER:
(D) The Ottawa foot and ankle rules should be used to determine the need for radiographs in foot and ankle injuries. A radiograph of the ankle is recommended if there is pain in the malleolar zone along with the inability to bear weight for at least four steps immediately after the injury and in the physician’s office or emergency department (ED), or tenderness at the tip of the posterior medial or lateral malleolus. A radiograph of the foot is recommended if there is pain in the midfoot zone along with the inability to bear weight for four steps immediately after the injury and in the physician’s office or ED, or tenderness at the base of the fifth metatarsal or over the navicular bone. The Ottawa foot and ankle rules are up to 99% sensitive for detecting fractures, although they are not highly specific. In this case there are no findings that would require radiographs, so treatment for the ankle sprain would be recommended. Compression combined with lace-up ankle support or an air cast, along with cryotherapy, is recommended and can increase mobility. Early mobilization, including weight bearing as tolerated for daily activities, is associated with better long-term outcomes than prolonged rest.
A 28-year-old female presents with a 3-month history of fatigue and postural lightheadedness. On examination she is diffusely hyperpigmented, especially her skin creases and areolae. A CBC and basic metabolic panel are normal except for an elevated potassium level. You order a corticotropin stimulation test. Prior to the corticotropin injection, you should order which one of the following tests to confirm that this patient has a primary insufficiency and not a secondary (pituitary) disorder?
A) ACTH
B) Aldosterone
C) Melanocyte-stimulating hormone
D) Renin
E) TSH
ANSWER: (A) A plasma ACTH level is recommended to establish primary adrenal insufficiency. The sample can be obtained at the same time as the baseline sample in the corticotropin test. A plasma ACTH greater than twice the upper limit of the reference range is consistent with primary adrenal insufficiency. Aldosterone and renin levels should be obtained to establish the presence of adrenocortical insufficiency, but these do not differentiate primary from secondary adrenal insufficiency. The hyperpigmentation of Addison’s disease is caused by the melanocyte-stimulating hormone (MSH)–like effect of the elevated plasma levels of ACTH. ACTH shares some amino acids with MSH and also produces an increase in MSH in the blood. TSH is not part of the feedback loop of adrenal insufficiency.
Routine follow-up blood tests for colorectal cancer survivors should include
A) carcinoembryonic antigen (CEA) levels only
B) liver function tests only
C) CBCs and CEA levels only
D) CBCs and liver function tests only
E) CBCs, CEA levels, and liver function tests
ANSWER: A
The Choosing Wisely campaign recommends checking only carcinoembryonic antigen (CEA) levels following curative treatment for colorectal cancer (SOR C). No routine laboratory studies such as a CBC or liver function tests should be ordered for follow-up.
A 56-year-old female comes to your office for evaluation of fatigue and shortness of breath. She has a history of type 2 diabetes mellitus, hypertension, hyperlipidemia, and obesity. Her diabetes has been well controlled, and a recent hemoglobin A1c was 6.7%. She reports that she has been more tired than usual for the past several months and that walking more than a block or going up a flight of stairs has now become difficult. She has no chest pain, palpitations, dizziness, or cough. She has had mild, stable lower extremity edema for years, and this is unchanged. She lives alone and is not sure if she snores. She has had difficulties with sleep for years and does not feel refreshed upon awakening. She does not use tobacco or drink alcohol.
On examination she has a blood pressure of 128/78 mm Hg, a pulse rate of 76 beats/min, a respiratory rate of 14/min, a temperature of 37.1°C (98.8°F), an oxygen saturation of 95% on room air, and a BMI of 38.2 kg/m2. Auscultation of the heart reveals a regular rate and rhythm with no murmur. Her lungs are clear to auscultation bilaterally. She has 1+ pitting edema of both lower extremities. A chest radiograph is normal and an EKG reveals normal sinus rhythm. Echocardiography shows a left ventricular ejection fraction of 60% without impaired diastolic function.
Which one of the following evaluations is most likely to reveal the cause of her fatigue?
A) 24-hour ambulatory blood pressure monitoring
B) Spirometry
C) A sleep study
D) CT angiography of the chest
E) Left heart catheterization
ANSWER: C
This patient has pulmonary hypertension that, based on her history, is most likely related to obstructive sleep apnea (OSA). Most patients with pulmonary hypertension have an underlying disease of the heart or lungs that leads to elevated pulmonary artery pressures. Common underlying conditions include chronic lung disease such as COPD, OSA, and left heart failure (with a reduced or preserved ejection fraction).
Additional considerations include chronic thromboembolic disease and primary pulmonary arterial hypertension.
This patient’s obesity and unrefreshing sleep make OSA the likely underlying cause of her pulmonary hypertension. She does not have clinical features of thromboembolic disease or a history of COPD. Her echocardiogram does not show heart failure, and she has no symptoms to suggest obstructive coronary disease. Ambulatory blood pressure monitoring can aid in the diagnosis and optimal treatment of hypertension, but this would be unlikely to relate directly to her pulmonary hypertension.
A 10-year-old male has an 8-mm induration 2 days after a tuberculin skin test. He shares a bedroom with his 18-year-old brother who was recently diagnosed with tuberculosis. There are no other historical or physical examination findings to suggest active tuberculosis infection and a chest radiograph is normal. Which one of the following would be most appropriate at this point?
A) Monitoring with annual tuberculin skin testing
B) Observation and repeat tuberculin skin testing in 3 weeks
C) Rifampin (Rifadin) daily for 4 months
D) Isoniazid daily for 9 months
E) Once-weekly isoniazid and rifampin for 3 months
ANSWER: (D) This patient’s close contact with a person known to be infected with tuberculosis (TB) places him at risk for infection, so screening for TB is indicated. For this patient, testing with either a tuberculin skin test or an interferon-gamma release assay is appropriate. Based on CDC guidelines an induration >/=5 mm at 48–72 hours following an intradermal injection of tuberculin is a positive test in individuals who have been in recent contact with a person with infectious TB, those with radiographic evidence of prior TB, HIV-infected persons, and immunosuppressed patients. For other individuals at increased risk for TB, the threshold for a positive test is an induration >/=10 mm at 48–72 hours. For those with no known risks for TB infection, the induration must exceed 15 mm in size to be considered positive. Once positive, there is no indication for additional skin tests.A positive screening test along with a review of systems, a physical examination, and a chest radiograph that do not show evidence of active infection confirms the diagnosis of latent TB. For children age 2–11 years, treatment with isoniazid, 10–20 mg/kg daily or 20–40 mg/kg twice weekly for 9 months, is the preferred and most efficacious treatment regimen. The shorter 6-month treatment course is considered an acceptable option for adults, but it is not recommended for children. The use of rifampin alone or in combination with isoniazid is also an acceptable option for adults but not for children under the age of 12.
A 73-year-old male with advanced degenerative arthritis of the knees asks what you would recommend for relief. He does not wish to have a total knee replacement. He says that NSAIDs have not been effective. Which one of the following would be the best recommendation?
A) Acetaminophen
B) Intra-articular corticosteroids
C) Intra-articular hylan GF 20 (Synvisc)
D) Physical therapy for quadriceps strengthening
E) Tramadol (Ultram)
ANSWER: (D) Quadriceps-strengthening exercises have been shown in good studies to stabilize the knee and reduce pain for patients with degenerative arthritis. Acetaminophen has not been shown to produce clinically significant improvement from baseline pain. Intra-articular corticosteroids can acutely relieve pain and effusions but do not affect moderate-term outcomes. Hylan GF 20 products are minimally effective. Opiates and other similar drugs are addictive and should be avoided.
Additional workup or referral to an endocrinologist for evaluation of precocious puberty would be indicated in which one of the following patients?
A) A 7-year-old female with some pubic hair
B) An 8-year-old female with breast buds
C) An 8-year-old male with some pubic hair and axillary odor
D) An 8-year-old male with penile enlargement
E) A 10-year-old female who has recently begun having menses
ANSWER: (D) Penile enlargement in an 8-year-old male is a sign of precocious puberty. Isolated sparse pubic and axillary hair growth and axillary odor is referred to as premature adrenarche, and represents high levels of dehydroepiandrosterone rather than activation of the hypothalamic-pituitary-gonadal axis that leads to puberty. The isolated findings of premature adrenarche are generally considered benign. An 8-year-old with breast buds and a 10-year-old with menarche are within the normal range of expected pubertal development. Penile enlargement typically represents full activation of the hypothalamic-pituitary-gonadal axis and warrants endocrinologic evaluation in boys younger than 9 years of age.
Which one of the following malignancies is associated with hereditary hemochromatosis?
A) Biliary carcinoma
B) Chronic myeloid leukemia
C) Hepatocellular carcinoma
D) Multiple myeloma
E) Pancreatic cancer
ANSWER: (C) Hereditary hemochromatosis is a genetic disorder of iron regulation and subsequent iron overload. Possible end-organ damage includes cardiomyopathy, cirrhosis of the liver, and hepatocellular carcinoma. Symptoms are often nonspecific early on, but manifestations of iron overload eventually occur. The diagnosis should be suspected in patients with liver disease or abnormal iron studies indicative of iron overload. A liver biopsy can confirm the diagnosis and the degree of fibrosis. Identification of such patients and proper ongoing treatment with phlebotomy may prevent the development of hepatocellular carcinoma and other complications of this disease. There is some data that suggests an association of breast cancer with hereditary hemochromatosis but not with any of the other malignancies listed.
A 67-year-old female with hypertension and atrial fibrillation has been taking warfarin (Coumadin) for the past 10 years. She has been hemodynamically stable for many years with no complications from her atrial fibrillation. She is scheduled to undergo elective bladder sling surgery for urinary incontinence. She does not have any other significant past medical history. Which one of the following would be the most appropriate perioperative management of her warfarin?
A) Continue warfarin without interruption
B) Discontinue warfarin the day prior to surgery and provide bridge therapy with low molecular weight heparin
C) Discontinue warfarin 2 days prior to surgery and restart it 2 days postoperatively unless there is a bleeding complication
D) Discontinue warfarin 2 days prior to surgery and restart it 5 days postoperatively unless there is a bleeding complication
E) Discontinue warfarin 5 days prior to surgery and restart it 12–24 hours postoperatively unless there is a bleeding complication
ANSWER: (E) Perioperative management of chronic anticoagulation requires an assessment of the patient’s risk for thromboembolism and the risk of bleeding from the surgical procedure. High-risk patients include those with mechanical heart valves, a stroke or TIA within the past 3 months, venous thromboembolism within the past 3 months, or coronary stenting within the previous 12 months. High-risk patients require bridging therapy with low molecular weight heparin, while patients at low risk do not require bridging anticoagulation. For low-risk patients, it is recommended that warfarin be discontinued 5 days prior to surgery and restarted 12–24 hours postoperatively. This patient is at low risk for thromboembolism because her CHA2DS2-VASc score is 3. A patient with atrial fibrillation should receive bridging therapy with a CHA2DS2-VASc score 6. This patient’s surgery is associated with a high risk for bleeding, so it is preferable to stop her warfarin 5 days before the operation
While on call for your group practice you are called to admit a 23-year-old female with a history of sickle cell disease who presented to the emergency department with chest pain, a cough, and shortness of breath. She has no history of recent hospitalization.
Physical Findings
Blood pressure 176/86 mm Hg
Pulse 103 beats/min
Respiratory rate 20/min
Temperature 37.8°C (100.0°F)
Oxygen saturation 89% on room air
A chest radiograph shows consolidation in the right lower lobe. In addition to oxygen, intravenous fluids, an intravenous third-generation cephalosporin, and pain management, which one of the following is important to include in the patient’s treatment plan?
A) Azithromycin (Zithromax)
B) Daptomycin (Cubicin)
C) Ertapenem (Invanz)
D) Gentamicin
E) Vancomycin (Vancocin)
ANSWER: A
This patient has acute chest syndrome (ACS), a serious vaso-occlusive complication of sickle cell disease (SCD). Its cause may be multifactorial, but infections are common and antimicrobials are indicated. However, the clinical course of ACS is significantly different from infectious pneumonia in patients without SCD, due to the damaged microvasculature that occurs in ACS. Studies have shown that atypical pathogens predominate in ACS and it is therefore important to treat all patients with ACS with antibiotics that cover Mycoplasma and Chlamydophila. Viral infections are also common, especially in children with ACS. Other possible pathogens include Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae. Therefore, the use of a third-generation cephalosporin along with azithromycin is the recommended antibiotic coverage.
In addition to antimicrobials, treatment includes supportive care with supplemental oxygen, intravenous fluids, pain control, and incentive spirometry. Depending on the degree of anemia seen, a simple blood transfusion or exchange transfusion is often indicated as well. Consultation with a hematologist is recommended in the care of patients with ACS. Even with appropriate care, mortality rates in ACS are as high as 3%.
An otherwise healthy 14-year-old male presents for evaluation of severe left groin and lateral knee pain. He has difficulty with his gait and has recently developed a limp. Physical examination reveals an obese male. Examination of the left knee reveals no swelling, no erythema, and no knee instability. He denies any recent trauma. The most likely diagnosis is
A. Ewing sarcoma
B. growing pains
C. Legg-Calvé-Perthes disease
D. patellofemoral syndrome
E. slipped capital femoral epiphysis
ANSWER: (E) The correct answer is slipped capital femoral epiphysis. Slipped capital femoral epiphysis is the most common hip disorder in adolescents, and it has a prevalence of 10.8 cases per 100,000 children. It usually occurs in children 8 to 15 years of age, and it is one of the most commonly missed diagnoses in children. Slipped capital femoral epiphysis is classified as stable or unstable based on the stability of the physis. The condition is associated with obesity and growth surges, and it is occasionally associated with endocrine disorders such as hypothyroidism, growth hormone supplementation, hypogonadism, and panhypopituitarism. Patients usually present with limping and poorly localized pain in the hip, groin, thigh, or knee. Diagnosis is confirmed by bilateral hip radiography, which needs to include anteroposterior and frog-leg lateral views in patients with stable slipped capital femoral epiphysis, and anteroposterior and cross-table lateral views in patients with the unstable form. Hip pain can refer pain to the knee also. Ewing sarcoma is typically accompanied by localized bone pain, a palpable mass (depending on location), prolonged fever, fatigue, weight loss, compression of local structures (bladder and spinal cord), symptoms due to bone marrow infiltration, and skin changes. Growing pains typically occur nocturnally, lasting for a few weeks at a time. There would be no associated limp or sequelae during the daytime. Legg-Calvé-Perthes disease is a disease affecting the hip due to temporary interruption in blood flow to the femoral head. This results in progressive injury and avascular necrosis. It results in permanent deformity of the femoral head, limping, and pain with ambulation. Patellofemoral syndrome is the most common cause of knee pain in the outpatient setting. It is caused by imbalances in the forces controlling patellar tracking during knee flexion and extension, particularly with overloading of the joint. Risk factors include overuse, trauma, muscle dysfunction, tight lateral restraints, patellar hypermobility, and poor quadriceps flexibility. Typical symptoms include pain behind or around the patella that is increased with running and activities that involve knee flexion. Findings in patients with patellofemoral syndrome range from limited patellar mobility to a hypermobile patella. To confirm the diagnosis, an examination of the knee focusing on the patella and surrounding structures is essential. For many patients with the clinical diagnosis of patellofemoral syndrome, imaging studies are not necessary before beginning treatment. Recent research has shown that physical therapy is effective in treating patellofemoral syndrome. There is little evidence to support the routine use of knee braces or nonsteroidal antiinflammatory drugs
A 25-year-old female presents to your office to discuss abnormal menstrual periods. She says that her cycles have always been irregular but she has not had any bleeding in 3 months. She also says she has gained 20 lb over the past 6 months. She is not taking any medications. You perform an examination and order laboratory tests. Her blood pressure is 110/72 mm Hg, heart rate 84 beats/min, respiratory rate 12/min, and weight 78.0 kg (172 lb) with a BMI of 29.5 kg/m2. She is noted to have moderate cystic acne. Her examination is otherwise unremarkable. A serum hCG measurement is negative and TSH, FSH, and LH levels are normal. Follow-up laboratory evaluation is significant for a total testosterone level 3 times the upper limit of normal and a normal 17-hydroxyprogesterone level.
Which one of the following would be most appropriate at this point?
A) An estradiol level
B) A dexamethasone suppression test
C) Karyotyping
D) CT of the abdomen and pelvis
E) MRI of the brain
ANSWER: D
This patient presents with mild symptoms of hyperandrogenism. Her initial laboratory results rule out pregnancy, thyroid disorders, and primary ovarian failure. The follow-up laboratory evaluation indicates significant hyperandrogenism. The rapid onset and high testosterone level suggest an ovarian or adrenal tumor that should be evaluated by abdominal/pelvic imaging. MRI of the brain is not helpful in evaluating hyperandrogenism. It would be appropriate in evaluating hypothalamic and pituitary causes of secondary amenorrhea such as the female athlete triad or other causes of stress and malnutrition that are associated with weight loss. A karyotype would be helpful in identifying the cause of primary amenorrhea. An estradiol level is not helpful in evaluating hyperandrogenism. A dexamethasone suppression test aids in the diagnosis of Cushing syndrome, which generally does not cause amenorrhea and is usually associated with stigmata of hypercortisolism, which this patient does not have.
You have diagnosed a 32-year-old female with moderate iron deficiency anemia, presumed to be due to chronic menstrual blood loss. She has no gastrointestinal or genitourinary symptoms, and no bruising or bleeding other than menstrual bleeding. Her vital signs are normal and a physical examination is unremarkable. You initiate a trial of oral iron therapy. Which one of the following would be the best way to assess the patient’s response to oral iron?
A) A reticulocyte count in 1–2 weeks
B) A repeat hematocrit in 2 weeks
C) A peripheral smear to look for new RBCs in 4 weeks
D) A serum total iron binding capacity and ferritin level in 6 weeks
ANSWER: (A) The reticulocyte count is the first and best indicator of iron absorption and bone marrow response to oral iron therapy in the treatment of iron deficiency anemia. An increase in reticulocytes is seen as early as 4 days, peaking at 7–10 days. The rate of production of new RBCs slows thereafter due to a compensatory decrease in erythropoietin as more iron becomes available. It typically takes 4–6 weeks before seeing recovery in the hematocrit, and for the RBC count and indices to normalize. However it is usually 4–6 months before iron stores are fully restored to normal levels, so treatment should continue for at least that long.
An 89-year-old female with a history of hypertension and glaucoma is brought to the emergency department by her family with shortness of breath. She has been trying to get her home ready for sale prior to moving into an assisted living facility. She says that she has not been sleeping well for weeks because she is worried about the move. On admission the patient has a blood pressure of 140/92 mm Hg, a pulse rate of 86 beats/min, a respiratory rate of 26/min, a temperature of 36.6°C (97.9°F), and an oxygen saturation of 95% on room air. A physical examination is normal other than faint basilar crackles. A chest radiograph shows a slightly prominent cardiac silhouette, peribronchial cuffing, and coarse perihilar lung markings. An EKG reveals a normal sinus rhythm with global T-wave inversion of the precordial and limb leads. Her troponin I peaks at 0.953 ng/mL (N 0.000–0.780). Echocardiography reveals a normal size right ventricle with moderate right ventricular hypokinesis, left ventricular apical ballooning, a left ventricular ejection fraction estimated at 30%, and a moderately increased pulmonary artery pressure estimated at 43 mm Hg. A radionuclide myocardial perfusion imaging study is normal. Which one of the following is the most likely diagnosis?
A) Acute coronary syndrome
B) Acute pericarditis
C) Cardiac amyloidosis
D) Takotsubo cardiomyopathy
E) Viral myocarditis
ANSWER: (D) Takotsubo cardiomyopathy (TTC) is also known as apical ballooning syndrome and stress-induced cardiomyopathy. It generally occurs in postmenopausal women with a mean age of 62–76 years. The clinical presentation is similar to that of acute coronary syndrome. Evaluation with an EKG, cardiac biomarkers, and imaging is needed to differentiate between these two conditions. This patient presents with classic apical and midsegment left ventricular hypokinesis, or apical ballooning, and a new T-wave inversion with modest elevations in cardiac troponin. While she has an identifiable characteristic emotional stressor, up to one-third of patients with TTC do not have an identifiable stressor. In this scenario, a negative myocardial perfusion scan makes coronary artery disease or acute coronary syndrome unlikely. Patients with viral myocarditis typically present with fever, myalgia, and signs and symptoms of heart failure following a viral syndrome. Cardiac amyloidosis is a restrictive cardiomyopathy that is typically associated with thickened walls of both ventricles and markedly dilated atria. Patients with acute pericarditis present with chest pain, a pericardial friction rub on examination, an ST-segment elevation on EKG, and a pericardial effusion on echocardiography.